Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 122/30.05.2019
Shri Avinash Goel, son Late Ishwar Prasad Goel,
R/o RZI-12Bm Old Som Bazar Gali, Mahavir Enclave,
Dabri, Delhi-110045 …Complainant
Versus
OP1: The Oriental Insurance Company Limited, through
Branch Manager, CBO-21, 10184,Arya Samaj Road.,
Karol Bagh, New Delhi-110035
OP2: M/s Vipul Medicrop (TPA) Private Limited,
515 Udyog Vihar, Phase-V, Gurgaon, Haryana -122016 ...Opposite Party
Date of filing: 30.05.2019
Coram: Date of Order: 08.11.2024
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
FINAL ORDER
Inder Jeet Singh , President
It is scheduled today for order (item no.1)
1.1. (Introduction to case of parties) – The complainant has grievances of deficiency of services and unfair trade practice against OPs that Medi-claim Policy (Happy family floater) no.272203/48/2018/183 valid from 17.02.218 to 16.02.2018 [hereinafter referred as insurance policy] was taken for himself, his parents and his family from OP1/Insurer to meet contingency. His father was suffering from fever, he visited Ekansh Nursing Home on 30.05.2018, he was prescribed medicine for five days but for want of recovery, on 02.06.2018 revisit of his father, he was advised admission on the same day in Ekansh Nursing Home. There was medical expenses of Rs.2,46,382/- incurred but the same were not reimbursed by OP1. That is why the present complaint for reimbursement of this amount with interest @ 18%pa, compensation of Rs. 1,00,000/- in lieu of harassment, costs of Rs.50,000/- and other relief.
1.2. The Insurer/OP1 opposed the complaint by filing detailed written statement. The Nursing Hospital, its doctor and staff failed to cooperate the Investigators as well as complainant also failed to provide documentary records asked for. The claim has not been rejected as yet. There is no deficiency of services or unfair trade practice on the part of OP nor it liable to pay any amount to. The OP1 is still ready and willing to process the claim subject to complainant and hospital cooperate and provide record.
1.3. The OP2/TPA was also served on 17.01.2018 with the notice on complaint and for want of its appearance, it was proceeded ex-parte on 05.04.2018.
2.1. (Case of complainant) –The complainant took medi-claim insurance policy from insurer/OP1. The OP2 is TPA of OP1. The complainant's father Shri Ishwar Prasad Goel was suffering from fever, body-ache and loss of appetite thus he visited Ekansh Nursing Home on 30.05.2018, where Dr. R. Parashar examined and prescribed medicine for five days. However, he did not get relief /recovery and when he visited again on 02.06.2018, he was advised and admitted in the nursing home. On 02.06.2018 itself, the complainant immediately informed by email to OP2 about hospitalization of his father in the nursing home. The complainant's father expired on 19.06.2018 during hospitalization.
2.2 After last rites, the complainant lodged claim with prescribed claim form with documentary records and bills of Rs.2,46,382/- for reimbursement by speed post vide receipt no. ED430965131IN dated 26.03.2018.
. On 28.06.2018, the complainant checked status of claim lodged on the website of OP2 and found that OP2 raised one query by demanding 'self-attested valid photo ID proof of patient in date of birth format" despite the fact that patient was already died on 19.06.2018; it was unrealistic requisition. However, the complainant replied the letter with other required document posted through speed post ED430967535IN dated 29.06.2018.
Since the complainant had not received the claim cheque or correspondence or any enquiry despite wait, therefore, on 05.07.2018, he checked claim status on the website of OP2, it had asked again query by demanding self-attested photo ID of the patient, which was replied by the complainant vide letter dated 05.07.2018 via speed post ED430967558IN dated 05.07.2018, while emphasizing that the patient had expired on 19.06.2018, which was already informed to the OPs. The complainant again awaited reply from the OPs but no response was received, thus he was constraint to check the status of claim on the website of OP2 on 13.07.2018, when it was discovered that there was third query by the OP, it was also replied by speed post dated 14.07.2018 vide receipt No. ED430967646IN. Again on 26.07.2018 the complainant checked the claim status on the same website, there was unethical forth query by the OP2, it was also replied by speed post dated 30.07.2018 vide receipt No. ED430967703IN.
2.3. Since there was deficiency of services of the OP, therefore, the complainant made an application under RTI Act, 2005 on 15.10.2018 by speed post receipt No. ED430968054IN to OP1, wherein the some query/relevant information was sought by the complainant. On 15.11.2018, the complainant checked the status of the claim on the website of OP2, he was shocked to see another query of OP2, it was also replied by letter dated 024.11.2018 to both the OPs through speed post receipt No. ED430968125IN and ED430968111IN.
On 22.11.2018 the complainant received reply dated 16.11.2018 to the RTI applications, then complainant issued a clarification letter dated 01.12.2018 through speed post vide postal receipt no. ED430968195IN.
2.4. Again the complainant checked the status on 02.04.2019 on the website of OP2, he found his claim has been rejected without any reason by the OP2. The circumstances are crystal clear that OP had no intention to pay the claim of the complainant, they have not been processing the claim under mala-fide intention. They failed to redress the grievances of the complainant besides they failed to issue single reply or response to the queries since it was complainant who always checked the status of claim at his own level on the website.
The complainant is a consumer, the OPs being service provider indulged in deficiency of services and in unfair trade practice by acting dishonestly to the disadvantage of the complainant by causing harassment, mental tension and agony, for which they are liable to compensate. The complainant took the policy for him, his parent and family as a bona-fide consumer by paying huge premium of Rs. 32,046/- but claim was not settled. That is why, the present complaint for reimbursement of medical bill besides other relief.
2.5. The complaint is accompanied with photocopies - of covering letters, email, policy, claim form, consent form, expenses detail, Pan card, bank detail, treatment record, RTI application etc.
3.1 (Case of OP1)- The complaint is opposed by OP1 that there is no cause of action against OP1, besides no deficiency of services or unfair trade practice on the part of OP1.
The claim of Rs.2,46,382/ is not maintainable or of interest component or compensation of Rs. 1,00,000/- or costs of Rs.50,000/- or other relief.
3.2. The complainant and the Ekansh Nursing Home did not cooperate with the TPA/OP2, when their investigators visited the Nursing Home for the purposes of verification and enquiry about the deceased patient Late Ishwar Prasad Goel, who was being treated in the said hospital but died there. M/s Super Security System was deputed for the purposes of investigation, who visited the hospital with the representative OP2, They have given independent reports. As per the report of M/s Super Security System, the investigating team was not allowed to visit the entire hospital and to provide certain documents including death certificate. The patient was admitted in that hospital, which was 22 km away from the residence of patient, for which no explanation was provided. The investigators have reported that hospital was non-cooperative completely.
Similarly, OP2 has given its report besides no doctor/nurse was in the hospital despite patient was in septic shock, a single doctor cannot make two visits in a day, which is against medical ethic. The treating doctor wishes not to meet them. Further, the complainant had reported the claim to OP2 regarding treatment of his father and some papers were reached to the office of OP2, however, when the claim was processed, then it was found that complainant failed to fulfill the queries raised by OP2/TPA and to furnish the requisite record. He also failed to provide deficient record for processing the claim.
3.3 The written statement replies majority of the paragraphs on merit being not denied, however, the OP1 very specifically deny to paragraph 15 of the complaint that the complainant visited the website of OP2 or on 02.04.2019 the complainant found his claim has been rejected by the OP2. In fact, a letter dated 08.02.2019 was issued by the OP2 in favour of OP1, while recommending grounds that claim should be repudiated but the OP1 has not repudiated the claim as yet as well as if complainant and hospital are ready to cooperate with the OP2, the claim still be processed. Let the complainant be directed to do so. However, the complaint was filed without cause of action and the delay in processing the claim was because of want of cooperation by the complainant and nursing hospital. The complaint was filed without any deficiency of services on the part of OP1. The complaint is liable to be dismissed.
3.5 The reply is supplemented with copies of – medical case investigation sheet, report of investigator and OP2’s letter dated 08.02.2018 recommending repudiation of claim to OP1.
4.1 (Evidence)- The complainant Shri Avinash Goel filed detailed affidavit of evidence, which is on the lines of complaint with the support of documents.
4.2. The OP1 also led its evidence by filing affidavit of Sunil Kumar Gupta, Sr. Divisional Manager and it is also replica of written statement of OP1.
4.3. Since there was no appearance or written statement of OP2/TPA, that is why it was proceeded ex-parte vide order 08.08.2019.
5. (Final hearing)- The complainant and the OP1 filed their respective written arguments. The parties were also given opportunities for making oral submissions, then Sh. Varun Dhingra, Advocate for complaint made the submissions but no oral submissions on behalf of OP1, although on earlier occasion Shri Mitlesh Sinha, Advocate was appearing for OP1. Therefore, the material available in the form of written arguments on behalf of OP1 will also be considered, while weighing with rival contentions.
6.1 (Findings)- The rival contentions are considered keeping in view the case as set up by the parties, their evidence especially the documentary record and statutory provisions of law.
6.2. By taking into account stock of all material, documents, features and circumstances, the provisions of law and Regulations, then following conclusions are culled out :-
(A) There is no dispute that the complainant had informed the OPs regarding hospitalization of his father in the Ekansh Nursing Home and subsequently claim form was also furnished with all the paper inclusive of discharge summary dated 19.06.2018 that patient/insured Sh. Ishwar Persad Goel was admitted on 02.06.2018 and he expired on 19.06.2018 during for treatment of POU with sudden cardiac attack. There was no cash less facility extended and the complainant has proved the bill of treatment of his father of Rs. 2,46,382/-, which was paid by the complainant.
(B) The complainant has proved the correspondence between the complainant and OP2, the TPA asked to furnish self attested copy of PANcard, Aadhar Card and valid photo ID proof, despite the patient was already died and it was also mentioned in discharge summary as well as in the claim form furnished to OP2.
The claim form specifically mentions that patient had died 19.06.2018 as indoor patient, discharge summary was also filed despite this the OPs had asked duly attested documents of the insured. Was it fair and proper on the part of OP2? How OP1 could justify it?
(C) The complainant has proved the reply to the query raised as well as record generated from the website of OP2. The OP2 abstained from the proceedings and such record proved remain unchallenged vis-à-vis OP has also not challenged such record. Otherwise, the complainant has proved the covering letters beside other correspondence that he had furnished all the requisite documents and answer to all the queries raised.
(D) The case of complainant is that the claim was repudiated by the OPs but accordingly to OP1 the claim was not repudiated, since OP2's letter dated 08.02.2019 to the OP1 is just recommendation for repudiation of the claim. The OP1 had not repudiated the claim. These facts are vehemently mentioned by the OP1 in paragraph of the 15 of its written statement and paragraph 6 of the affidavit of evidence.
Whereas, the complainant has not referred or mentioned of such letter of 08.02.2019 in paragraph 15 of the complaint, or otherwise. This letter has been introduced by the OP1 in its written statement
. In fact, the complainant has referring the other record generated from website of OP2, it is also at page no. 108 of the paper book and it clearly mentions that the status of claim as 'rejected', it is mentioned after many details and dates. To say the OP2 on its website has loaded the final outcome of claim and it clearly mentioned that the claim was 'rejected' and the complainant ascertained this information from that website. Otherwise, the complainant was not apprised of such status by any of the OPs.
(E) There is an occasion to go through the IDRA (TPA-Heath Services ) Regulations 2016 and its Regulation no. 3(2)(b) and proviso to Regulation 21, clearly shows that the TPA has no authority either to reject the claim or to communicate such rejection. The relevant Regulations are as follows :-
"[Regulation 3. Health Services by TPA:
(1) A TPA may render the following services to an insurer under an agreement in connection with health insurance business:
(a) to (g) xxxx…
(2) While performing the services as indicated at Regulation 3 (1) of these regulations, a TPA shall not-
a. xxx
b. Reject or repudiate any of the claims directly
(c ) to (e) xxx
"Regulation - 21. General guidelines to TPA in respect of services in relation to Health Insurance Policies:
(1) The TPA shall have in place the necessary infrastructure to extend the health services as required to the policyholders at all times.
(2) The TPA and the insurer shall be responsible for the proper and prompt service to the policyholder at all times.
(3) Scrutiny and handling of claims:
a. TPA may admit claims, authorize cashless facility and recommend to the insurer for the payment of the claim which shall be in line with the detailed claims guidelines issued to TPA by the insurers for the particular product:
Provided that the detailed guidelines as given by the insurer to the TPA for claims assessments and admissions shall be within the terms and conditions of the policy contract, the capacity requirements envisaged and the internal control norms put in place.
b. TPAs shall endeavour to collect all documents pertaining to the claims reported in electronic mode for seamless processing and for recommending to the insurer for payment or rejection as the case may be.
c. A TPA shall adopt the following procedure with respect to settlement of the claims:
i. In case of admissible claim, full or partial: In the communication addressed to the policyholder or claimant, the TPA shall state clearly the following:
a) “Your claim bearing No<Claim No> against policy issued by <name of the insurer> has been settled for Rs <Amit Paid> against the Amount Claimed for Rs <Claimed Amount> towards Medical Expenses incurred for treatment of <name of the Ailment> at <Name and City of the Hospital> for the period from <Date of Admission> to <Date of Discharge>”:
b) The granular details of the payments made, amounts disallowed and the reasons there for.
c) The details of (i) Grievance Redressal Procedure in place with the insurer (ii) Contact details of concerned Grievance Redressal Office and officer (iii) Procedure to be followed for approaching Insurance Ombudsman in case the policyholder or claimant is not satisfied with the resolution provided by the insurer (iv) Contact details of office of Insurance Ombudsman:
Provided that the above details shall be mandatorily included in the communication to the policyholder or claimant in every case where the TPA has disallowed any part of the claim.
ii. In case of inadmissibility of the entire claim
a) The TPA on its own shall not reject or repudiate the claim;
b) The decision and the communication with respect to rejection or repudiation of claim shall be sent only by the concerned insurer directly to the Policy holder or the claimant as the case may be".
It is apparent that the OP2 has put the rejection of claim on the website under its domain then how OP1 can say that the claim was not rejected. The OP1 has not proved any fact that OP2 was asked about such publication of such result of rejection of claim on the website of OP2. There is breach of Regulations by the OP2 and OP1 as impliedly consented thereto].
(F) The correspondence, letters and their reply have been proved by the complainant which clearly show and establish that the complainant had cooperated on all aspect to the OPs. So far OPs' plea against the Hospital/Nursing Home is concerned, it is not under the control of complainant. Otherwise the report of investigators/Annexure (R2) is undated and it is not known to whom it was written/addressed/sent and there is also nothing mentioned in this report that investigator had contacted or tried to contact the complainant for any purposes.
There is no report of OP2 filed or proved by OP1 as if its representative had actually accompanied the investigator and visited the treating hospital/Nursing Home. Thus, plea of OP1 in the written statement and evidence is hollow stand, without any proof or corroboration. Why OP1 with-held report of OP2, if it was containing relevant and material facts?
(G) All these contemporary circumstances are speaking themselves that OP2 had rejected the claim and it was loaded on the official website in public domain. The letter dated 08.02.2019 filed by the OP1 would not help the OP1 (stating that it was just recommendation for repudiation of claim but it remained dormant in the record of OP1), since the OP2 had declared and shown "rejection of claim" on its official website around 02.04.2019, which is subsequent to letter dated 08.02.2019. The OP1 had not challenged or discarded nor asked from OP2 to withdraw it from its official website. Thus, OP1 had endorsed rejection of claim by OP2, although OP2 had acted contrary to Regulations.
(H) Since the claim was not settled and informed to the complainant by OP1 but the circumstances are proving of "rejection of claim" without communicating to the complainant by OP1 but through OP2, then the complainant was constraint to file the complaint. The complainant is valid and proper, it cannot be treated pre-mature complaint. There is shortcoming of services and deficiency of services on the part of OPs.
The complainant has already proved the medical bill paid for the treatment of his father.
(I) The OP2/TPA has not filed any reply to complaint but abstained from the proceedings. The medical investigator appears to be of OPs. There is no proof of correspondence inter-se the OP1/insurer and its TPA/OP2 with regard to such non-cooperation to medical investigator, therefore, the OP1 could not prove these allegations which were so mentioned in the written statement. In fact, the OP2 was made a party to the complaint. it was served with notice and it has good and enough opportunity to put forward its grievances but it failed to put its own case of such grievances, if any, vis a vis OP1 has not proved any fact of such grievances or source of information of such grievances. The investigator's report (R2) is undated and it is not known to whom it is addressed by the said investigator.
(J) The complainant has also proved the email, claim form with detail of expenses, Lab investigation report, bills and discharges summary, by explaining that originals were already furnished to OPs. The same are not disputed.
(K) The complainant has proved medical record and bills related to treatment his father during hospitalization. The total medical bills paid amount is Rs.2,46,382/-.
6.3 The conclusions in aforementioned paragraph proves the circumstances and complaint against OPs vis a vis they do not establish case of OP1. Therefore, the complainant has succeeded in establishing the case of reimbursement of medical bill amount of Rs.2,46,382/-, which is within limit of sum insured of Rs. 3 lakhs.
6.4 Since the OP1 failed to reimburse the claimed amount of Rs.2,46,382/-and complainant had to spend the amount from his wallet,. The interest may not have been mentioned in the insurance policy contract but had his valid claim been settled, the complainant would not have been deprived of amount of Rs.2,46,382/-. It makes out case of complainant for interest on the amount spent by him. Thus, interest at the rate of 6%pa from the date 19.06.2018 of discharge summary till realization of the amount in favour of complainant and against OP1 will justify both sides.
6.5 The complainant seeks compensation of Rs.1,00,000/- in lieu of the inconvenience, harassment and agony suffered, besides cost of Rs. 50,000/- incurred by the complainant. The circumstances are manifesting that he had suffered inconvenience and harassment firstly by filing responses to queries, which was not raised by once but repeatedly that too were caught by the complainant, while accessing website of OP2 and then for want of settlement of claim and it was also not informed to complaint; the portal of OP2 was being browsed from time to time for want of any response from the OPs. Thence, complainant choose to file the present complaint. Therefore, compensation of Rs.30,000/- and cost of Rs. 15,000/- are being considered appropriate to the situation of this case and accordingly they are determined in favour of complainant and against the OP1.
7.1 In view of the above, the OP1 is directed to reimburse to complainant medical claim amount of Rs.2,46,382/-with interest at the rate of 6% pa from the date of death discharge summary of 19.06.2018 till realization of the amount to the complainant, apart from compensation of Rs. 30,000/- and cost of Rs. 15,000/-. This amount will be payable by OP1 within 45 days from the date of this order, failing to pay the amount in that time, then rate of interest will be 8% pa on amount of Rs.2,46,382/- (in place of interest of 6% pa). The OP1 may also deposit the amount by valid instrument in the Registry of this Commission in the name of complainant.
7.2 Since OP2 is TPA of OP1, it was a facilitator for the processing of claim for OP1. The relationship of insured and insurer is between the complainant and the OP1. Therefore, the complaint against OP2/TPA is dismissed, with directions that OP2 being TPA is bound by Regulations, which have been violated by OP2/ M/s Vipul Medicrop (TPA) Private Limited in this case by finally deciding and loading the result of 'rejection of claim' on its official website. The OP2 will not repeat it, being a direction.
8. Announced on this 08th day of November, 2024 [कार्तिक 17, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.
[Rashmi Bansal]
Member (Female)
[Inder Jeet Singh]
President
[ijs-139]
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